Asian Medicine and Globalization

By Joseph S. Alter

Medical systems function in specific cultural contexts. It is common to speak of the medicine of China, Japan, India, and other nation-states. Yet almost all formalized medical systems claim universal applicability and, thus, are ready to cross the cultural boundaries that contain them. There is a critical tension, in theory and practice, in the ways regional medical systems are conceptualized as "nationalistic" or inherently transnational. This volume is concerned with questions and problems created by the friction between nationalism and transnationalism at a time when globalization has greatly complicated the notion of cultural, political, and economic boundedness.

Offering a range of perspectives, the contributors address questions such as: How do states concern themselves with the modernization of "traditional" medicine? How does the global hegemony of science enable the nationalist articulation of alternative medicine? How do global discourses of science and "new age" spirituality facilitate the transnationalization of "Asian" medicine? As more and more Asian medical practices cross boundaries into Western culture through the popularity of yoga and herbalism, and as Western medicine finds its way east, these systems of meaning become inextricably interrelated. These essays consider the larger implications of transmissions between cultures.

• Language: English
• Publisher: University of Pennsylvania Press
• Release date: Mar 26, 2013
• ISBN: 9780812205251

Book preview

Chapter 1

Introduction: The Politics of Culture and Medicine

The chapters in this volume deal with the ways in which bodies of knowledge are manipulated to produce coherence and health, broadly defined. This book focuses on forms of medicine that tend to be linked, in practice and the imagination, to specific nations: India, China, England, and the United States most directly, but also Australia, Tibet, Japan, Singapore, and Germany. And yet the manipulation of health in any one of these places, borrowing ideas from any combination of the others—or from no clearly defined place at all—confounds the boundedness of these national entities. In other words, there is a powerful paradox manifest in the relationship between nationalism and transnationalism. This volume is designed to explore the nature of this paradox as it relates to medical practice and the development of medical knowledge.

Within the rubric of modernity it has become necessary, as Prasenjit Duara puts it, to rescue history from the nation (1995). The reason is that the legitimacy and power of nationalism is deeply vested in a particular construction of history. This construction is defined as an objective, authoritative, disinterested account of the past as such. It is, in part, the open-endedness and interpretability of the past that allows for it to be both captured and rescued, defined and redefined, according to different priorities. In this sense history is, simply, a more flexible medium than culture. As anthropologists have pointed out, culture can also be captured and rescued. However, by virtue of present tense, empirical temporality, the capture of culture—its strategic interpretation and manipulation—is often more covert than the capture of history. The heroic rescue of culture is championed overtly by those who claim value-free objectivity.

Culture and history come together at various points, and some of these points of convergence are much more prone to capture than others. Think of borders—what they mean, when they were drawn, and what the convergence of signification and demarcation means with regard to a whole spectrum of things for which the lines on a map are not particularly relevant but rather distort and disorient. If history must be rescued from the nation, the convergence of history and culture—as well as each of these unto itself—must be rescued from a world of partitioned and bracketed nation-states, and also from a worldview, reflected in academia as clearly as in business, that is predicated on the fractured and highly politicized nationalist perception that this entails. There are serious problems, in other words, in thinking about a large region of the world such as Asia—and where does that entity begin and end?—as though its history and culture could be subdivided according to geopolitical entities called China, India, Thailand, Korea, and Taiwan. This is a problem even for those whose topic of study—Buddhism in the tenth century, let us say—obviously crosscuts the borders of relatively old kingdoms and empires and modern states.

As more and more research is conducted on various medical systems in Asia by scholars from a range of disciplines, there is a tendency for the questions being asked to become more and more specific to the uniqueness of each particular case. This is good. We now know much more about medicine in China, Japan, Korea, Malaysia, Thailand, Sri Lanka, India, and Nepal—to string together a somewhat random list of countries—than we did even ten years ago. But it is also unfortunate. The structure of scholarship is invidiously and often invisibly structured by the priorities of the state: funding for research is linked to government interests and is often channeled through state bureaucracies. This can inadvertently produce the illusion that there is a tradition of medicine linked to each of these political entities, even when part of the illusion is that that tradition has undergone change through contact with other such traditions. So-called Traditional Chinese Medicine and Āyurveda provide the most striking examples. The fact that Āyurveda is the medical system of India goes almost without saying—and that is precisely the problem—even though the history of its development took place only in parts of what is now India, as well as what is now Pakistan, Afghanistan, Nepal, and Bangladesh, through an exchange of ideas that is probably more extensive than the borders of any one of these states or all of them put together.

Even a cursory overview shows that there is a tremendous amount of historical, theoretical, applied, and practical overlap between key concepts in the various medical systems of Asia. The similarity of such principles as yin/yang and prak ti/puru a, qi, and pr a, the three do a and the four Greek humors, or the five evolutive phases and the five mah bh ta elements in the respective traditions of East and South Asia seem almost to demand a cross-cultural comparative analysis. Similarly, various forms of Western medicine have been integrated into the practice of medicine to the east of wherever it is that the West is thought to begin, and this dynamic process of exchange has been important from the time of Scythian nomadism through to modern colonialism and the peripatetic introduction of German, Dutch, French, English, and American medicine into various parts of Asia.

To date, however, the extensive and detailed analyses of Asian medical systems have tended to focus on the bounded regional form of practice within the framework of contemporary nation-states. On the one hand there are studies of the introduction of Western medicine into specific countries. On the other hand there are studies of Chinese traditional medicine, Tibetan medicine, Malay humoralism, Japanese Kanpo therapeutics, and Āyurveda in India, Sri Lanka, or Nepal, for example. Even Unani, or so-called Islamic humoral medicine, which in its span from the Middle East to Southeast Asia seems to resist narrow, regional demarcation, has tended to be studied within the confines of subregional local practice.

There is no question that the local, regional, and national appropriation of medical traditions is a common and important framework within which theoretical and practical innovation has occurred. In the scheme of historical time, however, centralized state demarcation—at least on a regional scale—is a relatively recent development, and tends to obscure the way in which Asia, however that entity might be defined, is characterized by an integrated history of practice and theoretical innovation as concerns the development of medicine. Stretching from the periods of classical civilization up to the advent of European colonialism in West, East, Southeast, and South Asia, history suggests extensive interregional contact and communication by way of trade, political conquest, and religious proselytization. Beyond this, the seemingly more hegemonic and seamless forms of medical practice in the colonial and postcolonial periods also crosscut regional and state boundaries in important ways.

This volume explores the nature of the tension between nationalism and transnationalism on a smaller, more geographically delimited scale. The focus is on the following key question: when, why, and how is medicine linked to the social, political, religious, and economic culture of a state, and when, why, and how does it extend beyond these delimited, bounded frameworks of legitimation? In many ways this question is framed by institutionalized state politics—that which, quite literally, is established to police the borders. However, reflecting current developments in social theory and cross-cultural comparative analysis, this volume focuses on the nationalistic politics of culture rather than the politics of governments as such, on transnationalism as a cultural process linked to globalization rather than on the formal structure of economic trade or international relations.

Apart from the relatively numerous works on medical knowledge and practice in various regions of Asia, there is a small but significant body of literature that has clearly laid the foundation for an examination of the relationship between nationalism, transnationalism, and medicine in Asia. First and most significant is the work of Charles Leslie, whose two volumes Asian Medical Systems (1976) and Paths to Asian Medical Knowledge (coedited with Allan Young, 1992) have implicitly if not explicitly defined the link between regional expressions of nationalism and health care. Both volumes are comparative and force a consideration of parallel and converging themes in the history and culture of medical systems that have become associated with different state entities. This theme, along with the question of medical syncretism—which foregrounds questions of transnationalism and globalization—is taken up by Waltraud Ernst in Plural Medicine: Tradition and Modernity, 1800–2000 (2002). Although many contemporary anthropological and sociological studies of local practice situate medicine in the context of globalization, Connor and Samuel’s Healing Powers and Modernity: Traditional Medicine, Shamanism, and Science in Asian Societies (2001) is particularly noteworthy for the way each chapter problematizes the relationship between local and global manifestations of medicine and medical knowledge, and how the volume as a whole engages with medicine in the context of state entities, without presuming that the states in question exclusively define the context of practice. By bringing together essays that focus on healing in the modern states of Korea, Malaysia, and India, healing on the margins of Malaysia, Indonesia, and China, and healing that involves Tibetan medicine as practiced in China, Tibet, and India—and by integrating a concern with both shamanic practice and institutionalized medicine—this volume clearly anticipates a direct and critical problematization of the link between medicine and nationalism.

Clearly colonialism and the study of medicine under imperial regimes force a consideration of the intersection of ideas about the body, health, and healing as these ideas intersect in the context of politicized culture. Beyond David Arnold’s Colonizing the Body (1993), there is a rapidly growing literature in the field of colonial medicine and science studies (see, for example, Ernst and Harris 1999; A. Kumar 1998; D. Kumar 1991, 1995; Pati and Harrison 2001). Two other edited volumes, Imperial Medicine and Indigenous Societies (Arnold 1989) and Disease, Medicine, and Empire (MacLeod and Lewis 1988), situate medicine within colonialism, pointing out—implicitly if not always explicitly—the connection between the flow of knowledge through various parts of the empire and the resulting connection between nationalism and proto-transnationalism. As several scholars have pointed out (Chakrabarty 2000; Dirks 1998; Duara 1995; Kelly and Kaplan 2001; Prakash 1999) historians of colonialism must work against the logic of imperialism by refusing to let the trajectory of modern nationalism define the structure of history. By doing this it is possible to critically examine events that led up to the construction of state and cultural boundaries, without presuming where those boundaries are drawn, what they contain, or that the natural outcome was the formation of a thing called a state.

In his book The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine (1999), Shigehisa Kuriyama directly takes on the question of how, when and on what terms it is possible to compare medical knowledge that is deceptively similar and linked both to the history of different regions and the history of contact between those regions. What is unique about Kuriyama’s analysis, and why it is particularly significant here, is that it demonstrates how, apart from the sociology of practice—which is the primary concern of most anthropologists and historians of colonial medicine—medical theory is defined in the context of local practices that are influenced by the global flow of ideas and technology. As Kuriyama points out, what seems to be identical in fact—the pulse or a concept of vital breath—can be radically different in interpretation, and this disjuncture even crosscuts the genetic kinship between various theories and therapeutic techniques. For example, there may well be a direct developmental link between bloodletting and acupuncture (1999: 204)—a link that also connects Europe and Asia through an exchange of ideas about etiology and cure—but this does not at all mean that one place conceptualizes it in the same way as the other. There is, consequently, a critical tension, in terms of theory and practice, in the different ways traditional Asian medicine is conceptualized as either nationalistic or inherently transnational. Stretched to its extreme, this tension is reflected in questions that are probably impossible to answer, and thereby betray their own geopolitical bias—where does Greek medicine end and Chinese medicine begin? What sort of medicine does a physician practice when trained in the West—say Philadelphia—but gains experience that is integrated into practice while treating people in the East—say Beijing (see Brownell, this volume)? Building on the ideas developed by these and other scholars, this volume is designed to examine the relationship between medicine and the national and transnational politics of culture in terms of two sets of thematic questions.

The first set of questions concern the production of medical theory. How does theory reflect the political culture of its production, and does this political culture reflect a concern for containment and control or dissemination, teaching and popularization? When medical knowledge moves across borders—between India and China (Alter), between China and England (Lo and Schroer), between India and the United States (Selby and Van Hollen), between British India and England (Habib and Raina), between England and British India and the Dutch East Indies and the Netherlands (Kumar), and between China and the United States (Brownell)—does it retain its character as the medicine of a particular region or state? If so, how and why?

The second set of questions focus on the modern transnational flow of knowledge, capital, and people. Within Asia how do states concern themselves with the modernization of traditional medicine? How does the transnational hegemony of science enable or limit the nationalist articulation of alternative medicine in the context of specific states? How do discourses of science and New Age spirituality facilitate the transnationalization of Asian medicine?

Alter focuses primarily on the first set of questions by looking at how a quintessentially Chinese mode of therapy—acupuncture—has been integrated, in both theory and practice, into an Āyurvedic framework. The modern development of a distinct theory of Āyurvedic acupuncture is in some sense motivated by a clear sense of nationalism. Claims are made that the original theory of vital points and the manipulation of vital energy was developed in India and taken to China by traveling scholar-monks in the late classical period. The basis for such a claim is thought to be a theory of marma (vital points) articulated in various South Asian medical texts; according to some, the link between marma and n physiology, and a tradition of healing based on the manipulation of various different kinds of vital points, includes marma.

Beyond this, there is the complex question of technology and the relationship between needles and cauterizing tools on the one hand and the distinction between surgery and needling on the other. To what extent are these things the same and to what extent are they different? And then, how does the inherent ambiguity imbedded in the answer to this question structure the dynamic between nationalistic claims and transnational processes? Clearly there was contact between practitioners of medicine in what is now China and what is now India, and it is probable that there was a dynamic exchange of knowledge between scholars at any number of locations between East and South Asia. However, modern articulations of theory both recognize and deny this contact, and the more refined and complex a modern theory of Āyurvedic acupuncture gets, the more clearly it reflects the paradox and irony of a nationalism that depends on but seeks to transcend—or elide—a transnationalism that makes it possible.

Lo and Schroer are also concerned with the first set of questions, focusing on shifts in theory and meaning in the development of ideas about xie in traditional Chinese medicine. How xie has been translated differently at different times in China and England provides for an analysis of the relationship between political culture and theory. In very broad terms xie can be translated as evil, heteropathy or perversity; it literally means oblique, deviating, the opposite of zheng, that which is upright and straight. Although xie is linked to ideas about demonic possession and naturalistic illness, Lo and Schroer trace the earliest medical theories to social, political, and moral ideas on ritual and philosophy in general, and—striking a Pythagorean chord—to music in particular. They show how the link between music, mood, and behavior was problematized in the premodern period and how music and ritual served to subvert xie and promote harmony and balance.

Strikingly, a social and moral conceptualization of xie comes to inform medical theory as articulated in the Yellow Emperor’s Inner Canon:

As deviant music causes counterflow qi that disturbs the emotions and disrupts the state, so xie in a medical context brings with it a way of talking about the body in moral terms, terms which associate parts of the body with socially disruptive behavior.

In this, the state and the body are conceptualized in much the same way, and the two domains are linked metaphorically. Thus purgation, exorcism, and exile are in some sense all theoretically connected. This linkage finds interesting expression in the Nationalist period as such, and also in the nationalism manifest in the Maoist regime. In the former, the principle of xie did not conform to ideas about the scientific modernization of Traditional Chinese Medicine, and was purged from the literature, so to speak. In the Communist period the idea of xie, as it was linked to superstition and the evil of demonic possession, was labeled feudal and disruptive and was exorcized from theoretical texts.

The link in xie between the body, the state, and political culture also finds expression and elaboration in the context of transnationalism. One dominant form of contemporary acupuncture therapy in England derives from a lineage of development—via Japan and Taiwan—wherein xie continued to be recognized as theoretically and practically important during the time when it was purged from practice in the PRC. In the context of modern England, the principle of xie tends to be interpreted not as evil per se, but as the malignant environment and, at least by extension, the evil of the state’s environmental and economic policy, against which the body has to be protected.

Habib focuses on the history of Āyurveda and Unani in late nineteenth- and early twentieth-century India, when those involved in the nationalist movement were actively politicizing culture in general and the principle of swadeshi, or national self-reliance, in particular. In this context P. S. Varier, Hakim Ajmal Khan, and P. C. Ray came to be concerned with the modernization and revitalization of traditional Indian medical systems. Habib argues that early in the twentieth century Āyurveda and Unani came to be defined as traditional cultural systems, but also came to be identified as scientific systems that needed to be modernized. Verier, Khan, and Ray were involved in a complex process wherein the relationship between tradition and modernity was being worked out conceptually with reference to ideas about science and scientific theory. Thus, the key distinction between Āyurveda, Unani, and biomedicine was perceived to be one of relative progress and development rather than one of categorical ontological difference. What was perceived to be required was an epistemological shift rather than any kind of paradigmatic change. This allowed for tradition to be modernized in terms of science, with the essential Indianness of tradition being clearly preserved.

To preserve the Indianness of tradition, Habib and Raina argue, the cultural importance of science as a sign of Europe was played down in the discourse of modernization, using the logic of science itself: its claim to value-free, objective neutrality. At the beginning of the twentieth century the development of a discourse about the modernization of traditional medicine in terms of science helped to establish three critical axes that later in the century came to be recognized as the primary things that need to be changed in order to bring about reform and revitalization: the stagnation of knowledge, poor-quality education and training, and low-grade, poorly manufactured pharmaceuticals. While later in the century colonialism as such came to be blamed for the demise of traditional medicine along these axes, Habib and Raina point out that in the early part of the century the politics of culture was much more subtle. Although Verier, Khan, and Ray unselfconsciously looked to Western science, they did so in a context wherein there was at least a degree of parity, as reflected in Lord Hardinge’s public recognition that modern medicine owed a debt to the medicines of India for preserving knowledge that was lost in Europe during the dark ages.

In general Habib and Raina clearly show how nationalism not only finds expression as ideology or dogmatic positionality but is deeply vested in broad, transnational exchanges of ideas and techniques, in particular, ideas about the nature of science. With regard to medicine in particular, elemental, practical concerns about quality define the parameters of a debate about modernization that involves tradition.

Kumar reinforces and builds on many of the key points made by Habib and Raina by developing a comparative analysis of colonialism and medicine in British India and the Dutch Indies. He points out that although colonialism can be understood as a pervasive discourse of power, historians must not lose sight of the fact that in specific instances the development of medical knowledge—as one facet of this discourse—reflects insecurity, amazement, curiosity and frustration rather than the clear-cut certainty that one might associate with the larger, authoritarian project of imperialism. Kumar focuses on what might be called the subtexts of specific forms of colonial practice and knowledge construction by comparing and contrasting Dutch and British experiences in South and Southeast Asia during the eighteenth and early nineteenth centuries.

He begins his analysis by pointing out that although the tendency now is to make a categorical distinction between Western and non-Western forms of medicine, this distinction was not that sharp until the relatively recent institutionalization of germ theory. Prior to 1880, one must focus as much if not more on the institutionalization of medicine as on ideological positionality regarding categorical differences in medical theory. Following from this, early in the nineteenth century there was a degree of curiosity and amazement on the part of scholar-surgeons concerning the possible effectiveness of new substances and novel forms of treatment.

One aspect of colonial practice that Kumar analyzes is medical training. He shows that in contrast to the Dutch, the British in India had developed fine distinctions in terms of what to teach and whom to teach. In other words, the politics of health care administration was, in part, an issue of control over knowledge, and the proper transfer of knowledge between colonized and colonizer. In this context he points out that both the British and the Dutch very effectively exploited the hierarchical forms of social organization in their respective areas of rule.

At the fin de siècle the situation concerning medical theory had changed significantly with revolutionary advances in tropical medicine following germ theory and the epidemiology of epidemics. In both British India and the Dutch Indies this led to more hegemonic forms of public health administration and more intensive—and politicized—efforts in the institutionalization of medicine. Significantly, however, there was frustration on the part of colonial scientists studying tropical medicine, who felt as though their contextualized research was not being regarded as significant on account of being produced outside the centers of imperial authority, particularly London. As Kumar points out, there was also a degree of ambivalence on the part of colonial administrators regarding the role of philanthropic organizations. They provided much-needed funding for increased public health programs, but at the possible expense of the colonial government having to cede a degree of political and economic control.

In both Southeast and South Asia, a politicized, indigenous response developed in tandem with the expansion of colonial policy and practice. In British India a nationalist discourse was clearly articulated in the latter half of the nineteenth century as an issue that linked medicine to broader cultural concerns about self-rule and the value of tradition.